VWD Connect Foundation 2026 Provider Education Workshop on Severe VWD
Attendee Registration Form
Personal Information
First Name
*
Last Name
*
Professional Designation (NP, PhD, PT, GC, Med Student, etc.)
*
Name as you'd like it to appear on your badge (please indicate Dr., MD, NP, etc):
*
Institution as you'd like it to appear on badge:
*
City & State for badge
*
Street Address
Street Address Line 2
City
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Zip Code
Home Address
*
Street Address
Street Address Line 2
City
*
City
State
*
Zip Code
*
Postal / Zip Code
Email
*
example@example.com
Cell Phone Number (so we can reach you on-site)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Nonbinary
Prefer not to say
Other
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Discipline/Specialty
*
Adult Hematology
Pediatric Hematology
Hematology/Infusion Nursing
Orthopedics
Physical Therapy
OB/Gyn
Gastrointestinal
Family/Maternal Medicine
Genetic Counsellors
Hematology Social Workers
Mental Health Professionals
Nurse Practitioners
Other
Do you work with severe von Willebrand disease patients?
*
Yes
No
Expect to in the future
Do you work at a Hemophilia Treatment Center (HTC)?
*
Yes
No
Expect to in the future
Why do you want to attend the Workshop?
*
Did you attend the 2024 or 2025 Provider Workshop?
*
Yes, 2024
Yes, 2025
Yes, both
No, I will be a first time attendee
How did you hear about the Workshop? Please select all that apply.
*
Colleague recommended
Patient recommended
VWD Connect newsletter/email/website
Other organization communication
Attended a prior Foundation Workshop
Other
Please enter the name of the referring person/organization if applicable
Do you have a case you would like to present for discussion at the Workshop?
*
Yes
No
Not sure
What is a medical topic or question on Severe VWD you hope will be addressed at the Workshop?
*
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Hotel Booking and Accomodations
The Provider Education Workshop begins 5:00 PM Friday, Oct 9 thru 4:00 PM Sunday, Oct 11. The Foundation will provide a hotel room for attendees on Friday and Saturday night. If your travel arrangements require you to stay Sunday night to be able to complete the Workshop program at 4:00 PM, please select Sunday night also. If you wish to reserve additional nights at the hotel utilizing our block rate of $205/night, please use the link that will be provided in the confirmation email you will receive once you submit this registration.
Please indicate below what nights you will need a hotel room
Friday Night, October 9th - 1st Workshop Night
Oct 9
*
Yes
No
Saturday Night, October 10th - 2nd Workshop Night
Oct 10
*
Yes
No
Sunday Night, October 11th (Only if necessary to accommodate travel)
Oct 11
*
Yes
No
What room type would you prefer?
*
Two double beds
One king bed
No preference
Do you require any special room accommodations?
Do you have any dietary restrictions/needs?
Travel Assistance
The Foundation has a fund for attendees who are in need of travel assistance. These funds are for those who will not be able to attend due to the financial burden of travel and have exhausted all other sources of funding. If you apply, Jeanette Cesta, Executive Director, will contact you regarding next steps. If you are approved for travel assistance, you will book your own flights and email the itinerary and receipt. When you arrive at the Workshop, a reimbursement check will be ready for you. If flight costs are exceeding $500/round trip - please contact the Foundation to discuss PRIOR to committing to the flights.
Will you be applying for travel assistance?
*
Yes
No
Is travel assistance necessary for you to attend the Workshop?
Yes
No
Have you explored all potential avenues for funding your travel costs (your institution, employer, other sources)?
Yes
No
What do you estimate your flights will cost?
IMPORTANT TRAVEL INFORMATION
The West Palm Beach Marriott is approximately 3 miles from the Palm Beach International Airport (PBI now DJT). The hotel provides complimentary shuttle service. If flying, once you book your flights please email your itinerary to: JCesta@VWDConnect.org so we may plan arrival and departure staffing.
How will you be travelling to the Conference?
*
Flying
Driving
Other
Please complete your estimated arrival and departure dates and times below.
Arrival date?
*
-
Month
-
Day
Year
Date
Estimated arrival time?
*
Hour Minutes
AM
PM
AM/PM Option
Departure date?
*
-
Month
-
Day
Year
Date
Estimated departure time?
*
Hour Minutes
AM
PM
AM/PM Option
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Emergency Contact Information
Emergency Contact
*
First Name
Last Name
Relationship to Attendee
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is there anything else you would like us to know?
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Consents
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